Preventing Avoidable Admissions Among Assisted Living Elders

Saint Luke Home (SLH) is the only nondenominational, nonprofit academic assisted living
center (ALC) for low-income seniors who are ≥ 55 years old and in need of supervisory level
assistance in Tucson, Arizona. SLH residents have high behavioral health overlay with
presence of cognitive decline for some elders. Arizona Center on Aging and University of
Arizona Health Sciences have established an academic partnership with SLH. Currently,
interprofessional student teams conduct monthly screening clinics at SLH, but these visits
are limited to education, simple screening measures, and making general recommendations to
the elder's primary care provider via fax. Elders living at SLH have multiple providers for
their chronic conditions, and those providers may not be trained in geriatric care.

The documentation from incident reports shows that emergency medical service (EMS) calls are
made from SLH (capacity 64) approximately 60 times each year with emergency department (ED)
visits and hospital admissions following the incidences. In 2014, a total of 70 calls were
made, whereas 49 calls were made in 2015. The Director, who is a nurse by training, and staff
reported that many of these calls are medication-related and may be avoidable. As a quality
improvement process, a root-cause analysis was conducted by the PharmD fellows interested in
geriatric care and research with results reported. From the period of March 2015 to March
2016, a total of 65 calls were made to 911 from SLH that resulted in 39 ED visits and 6
hospitalizations by SLH elders. This was approximately 2 incidences/elder.

We believe forming an interprofessional team to bridge care and decrease EMS calls, ED visits
and hospitalizations can make a difference, a program entitled Preventing Avoidable
Admissions Among Assisted Living Elders (PA4LE). The interprofessional team will consist of
PI (PharmD with board certification in Geriatric Pharmacy), two doctor of pharmacy fellows,
Psychiatric nurse practitioner (NP), SLH director (nurse by training), and SLH resident
manager. All clinical activities will be supervised by a faculty team of geriatric attendings
- Dr. Fain (MD), Dr. Mohler (NP), and Dr. Lee (PI, PharmD). The PA4LE program will consist of
bi-weekly, 2-hour sessions, which will include home or clinic visits (elder preference),
educational sessions, and staff training at the SLH.

The purpose of the PA4LE program is to prevent EMS calls, ED visits and hospital admissions
from avoidable causes and decrease the use of high-risk medications among elders at the SLH.
We are modeling the current study intervention in part after the Coleman Care Transitions
Model, which is a patient and family-centered care transitions program from hospital to
community. The components of the model will be translated into use for ED/Hospital to ALC
transitions to avoid EMS calls, ED visits and hospital admissions/readmissions. To identify
avoidable causes for admissions, we used the study by Ouslander et al. that determined
frequency, causes and costs of potentially avoidable hospitalizations among nursing home
residents. A maximum of 50 participants will be enrolled in the study per the inclusion and
exclusion criteria.

Inclusion Criteria:

- One or more EMS calls made, ED visit or hospital admission in the past year, as
determined by the incidence report at SLH

Exclusion Criteria:

- A score of ≤ 22 out of 30 on the Montreal Cognitive Assessment (MoCA) during initial
assessment